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Family docs can treat simple sleep apnea: study

By Andrew M. Seaman

NEW YORK (Reuters Health) - With some basic training, primary care doctors and nurses could treat uncomplicated sleep apnea cases, according to a new study from Australia that highlights the potential cost savings compared to treatment at specialty sleep medicine centers.

The researchers, who followed 155 people with sleep apnea over six months, found that those treated by family doctors and nurses who had undergone a brief training regimen improved just as much on a scale that measures daytime tiredness as people who were treated by sleep specialists.

"We're suggesting that with the right training and motivation (sleep apnea) can be taken care of at the primary care level with the help of specialists," said Dr. Doug McEvoy, the study's lead author from the Adelaide Institute for Sleep Health at Repatriation General Hospital in Daw Park.

People with sleep apnea stop breathing for short periods when their airway collapses or gets blocked while they're asleep. The condition is most common among middle-aged, overweight adults and has been tied to a range of cardiovascular problems

In the early 1990s, it was estimated that between 2 percent and 4 percent of adults had sleep apnea, but with rising obesity, the condition is likely more common, McEvoy and his colleagues write in the Journal of the American Medical Association.

One recent study in Sweden found that half of women tested stopped breathing at least five times per hour while asleep (see Reuters Health article of Sep. 7, 2012 here: http://reut.rs/Zj2TKg).

Aside from weight loss, one of the most common treatments for sleep apnea is continuous positive airway pressure, or CPAP, in which a machine delivers air through a mouthpiece all night. A CPAP unit costs between $1,000 and $2,000.

Previous research has demonstrated that sleep specialists can safely use at-home sleep testing devices and outpatient care to manage sleep apnea, and McEvoy's team speculated that primary care doctors could do the same with some training.

For the new study, the researchers recruited patients between 25 years old and 70 years old, who were seeing one of 34 doctors in Southern Australia between September 2008 and June 2010.

The doctors, as well as community-based nurses, went through a training program developed by sleep medicine specialists and accredited by the Royal Australasian College of General Practitioners. It included a six-hour course taken by all the doctors and nurses, plus, for the nurses, a five-day in-service training with specialist nurses at a sleep center.

The main interventions the primary care providers were able to offer after the training were home diagnostic testing, CPAP, a special jaw splint that helps keep the airway from collapsing or referral for upper airway surgery.

At the beginning of the study, each patient completed a questionnaire about whether they were at risk for sleep apnea. They then wore a device at home while they slept that recorded how often they stopped breathing.

Of the 155 patients found to have sleep apnea, 81 were treated by their primary care physicians and nurses. The other 74 patients were sent to sleep specialists.

At the beginning of their treatment, the participating patients all scored, on average, around 13 on a scale that rates daytime tiredness from zero (not sleepy) to 24 (extreme sleepiness). A score of 8 on the scale represents mild tiredness, for example.

After six months of treatment, the average daytime tiredness score fell to about a 7 in both groups. Their scores on tests measuring other symptoms of sleep disorders and sleep apnea also fell about the same amount in both groups.

McEvoy told Reuters Health that taking care of patients in a primary care setting saved about 40 percent in costs, compared to patients who went to a sleep specialist.

In this study, it cost about $1,600 for a primary care doctor to treat a patient with sleep apnea, compared to $2,600 for a specialist to provide the care.

"I think this paper is important, because it shows primary care physicians are capable of identifying this population that probably can be taken care of by primary care doctors who have trained personnel," said Dr. Seva Polotsky, who studies sleep apnea at Johns Hopkins University School of Medicine in Baltimore.

But Polotsky, who was not involved with the new study, pointed out that sleep apnea patients shouldn't expect to be treated by their family doctors right now, because most physicians don't have the needed training.

SOURCE: http://bit.ly/JOTmp1 Journal of the American Medical Association, online March 12, 2013.

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